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Full text of "U.S. Navy Medicine Volume 68, Number 6 June 1977"

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VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM Paul Kaufman, MC, USN 
Deputy Surgeon General 


Sylvia W. Shaffer 


June Wyman 


Virginia M, Novinski 


Nancy R. Keesee 


Contributing Editor-in-Chief: 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT E.E. McDonald 
(DC); Education: CAPT J.S. Cassells 
(MC); Fleet Support: CAPT R.W. Jones 
(MC); Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve: CAPT N.V. 
Cooley (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research: CAPT 
C.E. Brodine (MC); Submarine Medicine: 
CAPT H.E. Click (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or ettracl from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members, Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy. Bureau of Medicine and Surgery (Code 0010}, 
Washington. D.C. 20372. Telephone: (Area Code 202) 
254-4253, 254-4316. 254-4214; Aulovon 294-4253, 294-4316, 
294^4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35). 



Volume 68, Number 6 
June 1977 

CHAMPUS changes 

T Readership survey 

3 From the Surgeon General 

4 Department Rounds 

NRMC Okinawa: When the Army goes Navy 
. . . The Navy's eye site 


9 NAVMED Newsmakers 

10 On Duty 

Field Medical Service School: Combat training that works 

12 Scholars' Scuttlebutt 

Reflections in the Wake: Two Decades of Navy Medicine 
CAPT T. Richter, MC, USN 

14 Policy 

Safety in anesthetizing areas , . . Disposing of health and dental 
records . . , Mass screening for blood donor eligibility 

16 Notes and Announcements 

Applicants needed for Hospital Corps "C" schools . . . NRMC 
Portsmouth nursing courses . . . Abbreviated clinical residencies 
available . . . Retirement point credit for professional meetings . . . 
Retired pay computation changes 

17 Features 

The Mysteries of Sleep 
L.C. Johnson, Ph.D. 

22 Professional 

Managing Emergencies in the Dental Office 
CAPT E.L. Mosby, DC, USN 

26 Missed Fracture Dislocation of the Elbow with Translocation 
of the Radius 

CDR A.H. Crawford, MC, USNR 
CDR E.F. Evans, MC, USN 

COVER: For 79 years, our combat forces have been able to count on 
Navy hospital corpsmen for competent medical care under the worst 
field conditions. One reason: corpsmen are well trained for combat duty 
at field medical service schools. This month, U.S. Navy Medicine marks 
the Hospital Corps' 79th birthday with a feature on life at the Field 
Medical Service School in Camp Pendleton, Calif, (page 10). 


What do you think of US NAVY MEDICINE? 

We are constantly seeking to serve our readers and to im- 
prove the quality of US NAVY MEDICINE. That's why we'd 
like to know your ideas about this magazine— what you expect 
and need to know from the official journal of the Navy Medical 

If you will fill in and return this questionnaire, you can help 
us make US NAVY MEDICINE more responsive to your 

Feel free to tell us any suggestions you may have concern- 
ing US NAVY MEDICINE; if necessary, attach a separate 
sheet for your ideas. 

After completing the survey, fold it so that our address 
faces out, staple, and mail. 

1 . You are now (circle one number) 

1 a member of the regular Navy 

2 a member of the Naval Reserve on active duty 

3 a member of the Naval Reserve not on active duty 

4 other military, or Public Health Service 

5 a civilian health care professional 

6 other 


How would you rate US NAVY MEDICINE'S coverage of 
activities in the five Medical Department corps? (Circle the 
number under the appropriate column.) 






5. Medical Corps 




6. Dental Corps 




7. Medical Service 





8. Nurse Corps 




9. Hospital Corps 




Explain your answers 

to que 

sstions 5-9: 

Would you like to see more coverage, the same amount of 
coverage, or less coverage of the following topics in US NAVY 
MEDICINE? (Circle the number under the appropriate 

More Same 

Your pay grade is 


0-7 to 0-9 


0-4 to 0-6 


0-1 to 0-3 


E-7 to E-9 


E-1 to E-6 




Medical Department policy 

1 ' 




Personnel changes 





Medical Department history 





Facility construction 





Career planning and opportunities 





Education and training 





New programs of health care 






Professional meetings and 






Technical medical and dental 





How often do you read the following sections of US NAVY 
MEDICINE? (Circle the number under the appropriate 


3. If a member of the Navy Medical Department, 

1 Medical officer 

2 Dental officer 

3 Medical Service Corps officer 

4 Nurse Corps officer 

5 Hospital corpsman 

6 Dental technician 

4. How often do you see US NAVY MEDICINE? 

1 Every month 

2 Every other month 

3 Seldom 

4 This is the first issue I have seen 

5 Other 



Once in 


Never saw 

or often 


read it 







you are a 20 


Scuttlebutt 1 





Notes and 

Announcements 1 






I nstructions and 


Directives 1 






Newsmakers 1 






Rounds 1 





Clinical Notes 1 






papers 1 





Enlisted Scene 1 





On Duty 1 





I ndependent 

Duty 1 





Education and 

Training 1 




Volume 68, June 1977 

The following articles and subjects appeared in US NAVY 
stories? (Circle the number under the appropriate column.) 


worth- Not Worth- Did not 
bad less see story 

MEDICINE during the past year. How would you rate these 

31. "Collision at Sea" 
(medical care during 
Kennedy-Bel knap 

32. " Hope for t he Queasy' ' 
{Navy research on 
motion sickness) 

33. "On the Run" (how 
Medical Department 
members keep in shape) 

34. Women in the Medical 

35. "Fleet Liaison: Cover- 
ing the Waterfront" 

36. Medical Department 
Equal Opportunity 




worth- Not Worth- Did not 

while bad less 

37. Series of clinical notes 
on how to treat head- 

38. "Let's Stop Prescribing 
Cold Medications" 

39. Medical support in 
Antarctica during 
Operation Deep Freeze 

40. "Reducing Length of 
Patient Stay" 

41. Managing child abuse 

at NRMC Camp Lejeune, 

42. Report of Surgeon 
General's Annual 
Specialties Advisory 

see story 


Do you have any additional comments, suggestions or complaints about US NAVY MEDICINE? 

L I I I L_J I I (Do not mark these boxes.) 


Bureau of Medicine and Surgery 
Washington, D.C. 20372 

Official Business 
Penalty for Private Use, $300 





U.S. Navy Medicine 

Bureau of Medicine and Surgery (Code 0010) 

Washington, D.C. 20372 

U.S. Navy Medicine 

From the Surgeon General 

Hospital Corps: 

The Medical Department's Foundation 

ON 17 JUNE, the Navy Hospital 
Corps will observe its 79th anniver- 
sary. Over the years, many words 
have become associated with Hos- 
pital Corps men and women and 
their deeds: honor, patriotism, in- 
telligence, selflessness, heroism, 
sacrifice, unfailing devotion to duty. 
No other group has shared as fully 
the call to service as has this, the 
proudest of our Medical Depart- 
ment corps. 

Hospital Corps men and women 
perform in arenas as broad as the 
mission of Navy medicine. Their 
tasks include the comforting smile 
and the gentle word at the bedside 
of the sick, service in the laboratory 
and the clinic, aid to Marines in 
combat and to injured sailors at sea. 

The message I have for Hospital 
Corps members is simple and 
direct: You are the foundation of the 
Navy Medical Department. Without 
you, we cannot fulfill our mission. 
We depend upon your energy, skill, 
and willingness to accomplish both 
extraordinary and ordinary assign- 
ments. Leadership, example, and 

the ability to learn and to follow are 
demanded of you all . Do not become 
complacent. Do not abandon your 
desire to learn. By increasing your 
skills and knowledge, make your- 
selves ready for the future, what- 
ever it may bring. 

Be patient, be understanding, but 
challenge our system— you are cer- 
tain to make it better. Remember, 
your being the best has brought 
Navy medicine to where we are to- 


Vice Admiral, Medical Corps 

United States Navy 

VADM Arentzen talks to the crew aboard the USS Independence 

Volume 68, June 1977 

Aerial view of U.S. Naval Regional Medical Center Okinawa, Japan 

Department Rounds 

When the Army Goes Navy 

It could have been any Navy 
change of command ceremony. The 
outgoing commanding officer and 
his replacement trooped the line to- 
gether and saluted the colors as 
family, friends, and a scattering of 
VIPs looked on. The new CO gave a 
speech. At the end, there was a 
hefty piece of cake for everyone. 

But some things were decidedly 
out of character. The former CO 
wore a green uniform, while his 
successor wore full dress whites. 
The color guard consisted of three 
Army and three Navy enlisted men. 
And for the celebration, there were 
two cakes: one with the seal of the 
Bureau of Medicine and Surgery, 
the other with the insignia of the 
Army Medical Department. 

Transition. That's how it was at 
Camp Kuwae, Okinawa, on 28 Feb 
1977, when U.S. Army Hospital 
Okinawa became a naval regional 
medical center. The man in green 
was Army COL Emwood Odom 
(MC), commanding officer of the 
Army hospital; his Navy relief was 
CAPT Charles S. Lambdin (MC), 
who reported from National Naval 
Medical Center in Bethesda, Md. 

The colorful ceremony capped off 
a busy year, during which Army and 

Navy transition teams worked tire- 
lessly to iron out a smooth transfer 
of personnel and functions. It all 
began in December 1975, when the 
Office of Management and Budget 
directed the Army to transfer some 
support services in Japan to other 
military services. The Navy, as the 
"dominant user" of military facili- 
ties in the Western Pacific, was 
tapped to take over the Army hos- 
pital, Makiminato dispensary and 
Evans dental clinic on Okinawa, as 
well as the Army medical laboratory 
at Sagami-Ono, Japan. 

Negotiations for the changeover 
got under way in March 1976, when 
a team of Army personnel and 
Bureau of Medicine and Surgery 
representatives traveled to Okinawa 
to do the advance work for the 
transfer. In July 1976, the Navy sent 
six Medical Service Corps officers 
and some senior hospital corpsmen 
to Okinawa to hammer out a trans- 
fer plan. The goals: to negotiate 
memoranda of understanding and 
interservice support agreements 
needed to transfer functions from 
the Army to the Navy, and to set up 
internal operating procedures for 
the naval regional medical center. 
The transition from Army to Navy 

COL Odom and CAPT Lambdin troop 
the I i ne at change of command 

Army-Navy color guard presents colors to 

RADM R.G. Williams, Jr. and CAPT 
Lambdin cut cake to celebrate transition 

\FT Lambdin and COL Emwood Odom 



Main entrance of U.S. NRMC Okinawa 

personnel was planned in phases, 
with Navy health care specialists 
reporting aboard around the same 
time their Army counterparts left. 

Full service. When those Navy 
replacements arrived at their new 
duty station, they found an impres- 
sive facility. With an operating 
capacity of 350 beds and a full range 
of specialty services, the hospital is 
one of the largest medical facilities 
in the Far East. 

Built of concrete and reinforced 
steel to withstand typhoons, the 
hospital is a far cry from the Army's 
first medical facility on Okinawa: a 
group of tents hastily set up in April 
1945 after U.S. forces landed on the 
island. That tent hospital was the 
end point of a complex patient evac- 
uation chain which stretched over 
the south shore of the island. Lit- 
ters, three-quarter ton trucks, tanks 
and ambulances were used to get 
patients from combat areas to the 
tents, where medical personnel 
often worked 24 hours without 

After World War II, several Army 
field hospitals on Okinawa were 
consolidated at Camp Mercy, where 
the 9th Station Hospital grew from a 
"canvas city" to an orderly group of 
quonset huts. During the Korean 
conflict, the Camp Mercy hospital 
supported U.S. operating forces as 
well as United Nations forces in the 
Philippines, Formosa and Okinawa. 

Construction was begun in 1955 
on the hospital used today, and the 
facility was opened to patients in 
1958; six years later, a 125-bed wing 
was added, giving the building a 
potential capacity of 700 beds. 

When Okinawa was returned to 
the control of the Japanese Govern- 
ment on 15 May 1972, the Army 
established its U.S. Army Medical 
Department Activity, Japan, with 
headquarters at the Camp Kuwae 
hospital. In last February's cere- 
mony, that Army activity closed its 
doors for good, leaving the Navy to 
carry on its tradition of providing 
quality medical care to military 
members in the Far East. 

—Story contributed by LTJG G.R. Mc- 
Dougall (MSC). Photos by HM2 E.W. Larson 

Health Benefits 



Rules of the Civilian Health and 
Medical Program of the Uniformed 
Services (CHAMPUS) will be en- 
forced more strictly, and program 
provisions will be easier to inter- 
pret, because of a comprehensive 
new CHAMPUS regulation recently 
announced by the Defense Depart- 

Robert N. Smith, M.D., assistant 
secretary of defense for health af- 
fairs, said that the new regulation 
will help beneficiaries determine 
what costs CHAMPUS covers or 
shares, eligibility requirements for 
the Program, and the procedures 
for submitting claims. The regula- 
tion also introduces an appeals 
procedure under which beneficiar- 
ies and providers can have disputed 
claims reviewed. 

Provisions of the regulation were 
implemented on 1 June for outpa- 
tient services and supplies, and for 
new inpatients. Care of currently 
hospitalized, long-term inpatients 
will be reviewed to determine 
whether the treatment being ren- 
dered meets requirements of the 
new regulation. If the care fails to 
meet requirements, these inpatients 
will receive a 90-day extension be- 
fore benefits are terminated. The 
earliest date on which any 90-day 
notice of termination will be mailed 
is 1 August, which means that no 
inpatient benefits will be terminated 
before 1 November. 

Quality emphasized. Dr. Smith 
pointed out that the regulation 
emphasizes quality of services, to 
ensure that beneficiaries receive 
appropriate treatment from quali- 
fied providers. He said it also 
protects the Government from pay- 
ing for medically unnecessary pro- 
cedures and services, and thus con- 
tributes to better control of 
CHAMPUS costs — an area about 

Volume 68, June 1977 

which Congress has been con- 
cerned. The regulation encourages 
beneficiaries and sponsors to exer- 
cise care in obtaining medical ser- 
vices — the same caution expected of 
beneficiaries under other health in- 
surance programs. 

The new regulation does not 
change the basic CHAMPUS bene- 
fit package. It does, however, 
clarify CHAMPUS policy and intent 
in several areas that had been 
vague or had never been addressed. 
For example, the regulation speci- 
fies that special education under the 
Program for the Handicapped is 
. covered only if state and local school 
jurisdictions cannot provide or pay 
for adequate special education. 
Also, coverage for alcohol rehabili- 
tation is now limited to three reha- 
bilitative inpatient stays. 

Clear definitions. Dr. Smith said 
the regulation contains clear defini- 
tions of benefits available through 
CHAMPUS. He noted that some 
beneficiaries have experienced fi- 
nancial hardship because they did 
not learn of the coverage provided 
by CHAMPUS, and eligibility re- 
quirements for the Program, until 
after they received care. Another 
source of confusion and inequity 
was that contractors interpreted 
CHAMPUS policy differently in 
paying claims. 

The regulation authorizes the 
director of CHAMPUS to waive any 
requirement in the regulation if the 
requirement is not set forth in any 
law governing the Program. For ex- 
ample, the director could use this 
authority to extend benefits for a 
new medical procedure not covered 
by the regulation. However, this 
authority will be used only under 
unusual circumstances, and will not 
be used to deny anyone his rights 
under law or under the CHAMPUS 

Appeals. Although an informal 
appeals mechanism has always 
existed for CHAMPUS beneficiar- 
ies, the formal procedures spelled 
out in the regulation are new. A 
contractor's decision may be ap- 
pealed in five steps: informal review 
by the contractor, reconsideration 

by the contractor (any decision in- 
volving less than $51 is final at this 
level), review by OCHAMPUS (the 
final level for decisions involving 
$300 or less), and an independent 
hearing; as a last resort, the bene- 
ficiary can appeal the decision to the 
assistant secretary of defense for 
health affairs. A decision made by 
the CHAMPUS office can be ap- 
pealed on four levels: informal re- 
consideration by CHAMPUS, for- 
mal CHAMPUS review, an inde- 
pendent hearing (only for decisions 
involving over $300), and referral of 
the decision to Dr. Smith's office if 
the first three steps fail to satisfy 

the beneficiary. 

The CHAMPUS regulation was 
published in the Federal Register 
on 4 April 1977, as a DOD operating 
policy, and interested organizations 
and individuals were invited to com- 
ment. All comments will be con- 
sidered and may be incorporated in 
a revised regulation. 

Additional information on the 
new CHAMPUS regulation may be 
obtained from health benefits coun- 
selors at military medical facilities 
or by writing to OCHAMPUS, 
Denver, Colo. 80240, or to the 
Bureau of Medicine and Surgery 
(Code 73), Washington, D.C. 20372. 


The Navy's Eye Site 

"Join the Navy and see the 
world' ' is more than a Navy recruit- 
ing slogan promising world travel. 
At the Naval Ophthalmic Support 
and Training Activity in Yorktown, 
Va„ the emphasis is on seeing — 
with the best possible prescription 

The ophthalmic facility, under the 
command of CAPT M.J. Testa 
(MSC), fabricates more than 30,000 
pairs of spectacles each month for 
active-duty and retired uniformed 

services personnel. The activity's 
primary concern is providing oph- 
thalmic support services to optome- 
try officers and ophthalmologists at 
Navy medical facilities worldwide. 

A complete range of military eye- 
wear is fabricated at the Yorktown 
facility, including clear and absorp- 
tive lenses in all single-vision, bi- 
focal, trifocal, full-field and lenticu- 
lar aspheric categories, as well as 
lenses for special equipment such 
as aviation goggles and gas masks. 

Interior of ophthalmic lab, where some 30,000 spectacles are made each month 

U.S. Navy Medicine 

(The Navy also operates 13 other 
ophthalmic service units that proc- 
ess only single-vision spectacles.) 
Some 76% of all lenses fabricated at 
the Yorktown activity are single 
vision, while 17% are bifocal and 
7% are other types of multifocal 
lenses and special types such as gas 
mask inserts. A standard black 
frame is specified for all Navy 
glasses except special types. Ap- 
proximately 15% of lenses fabri- 
cated by the facility are tinted. 

Lenses are made from both 
finished and semi-finished stock, 
most of which is supplied by the 
Defense Personnel Support Center 
in Philadelphia. Semi-finished 
lenses are surfaced, polished and 
edged in the Yorktown laboratory. 
All Navy optical specialty prescrip- 
tions are also filled there. 

Plastic lenses. Some 93% of the 
lenses fabricated at Yorktown are 
made of optical plastic, although 
some glass lenses are still fabri- 
cated for certain applications. 
"Plastic lenses weigh about half as 
much as glass lenses of comparable 
size and have good impact resistant 
qualities," says CAPT Testa. 

The Navy fabricated most specta- 
cles with glass lenses until Decem- 
ber 1972, when the Bureau of 
Medicine and Surgery directed the 
Yorktown laboratory to conduct a 
field evaluation of glass and plastic 
lenses. "Glass and plastic lens 
spectacles were issued to Navy and 
Marine Corps personnel overseas 
who used them under actual battle 
conditions," says CAPT Testa. 
"After one year, the men were 
asked to return their eyewear to us 
for examination and evaluation. 
Also, questionnaires were distrib- 
uted asking the men about the per- 
formance of the two types of eye- 

"A significant number of the 
glass lenses had shattered, but not 
the plastic lenses," CAPT Testa 
notes. "There were scratches on the 
plastic, but the lenses were still 
serviceable and kept the man on the 
line." Men who returned question- 
naires were almost unanimously in 
favor of the plastic lenses, with 

The lab has some 75 spindle surlacers 

Technician surveys optical stock items 

r r 

HM2 Martin checks polishing cylinders Inspecting finished pair of glasses 

wearers citing light weight and 
impact resistance as advantages. 

Orders processed. The Yorktown 
facility stocks about 2,400 different 
ophthalmic lenses, plus 1,000 other 
ophthalmic supplies such as surfac- 
ing pads and cleaning solution. "In 
the military, there is always the 
possibility of mobilization, so we 
keep plenty of materials on hand at 
all times," says CDR J.G. Wilcox 
(MSC), executive officer. 

Emergency prescription requests 
are received by official dispatch or 
telephone at all hours. Single-vision 
orders are processed in 24 to 36 
hours, multifocals within 72 hours. 

The lab's staff includes four offi- 
cers, 118 enlisted members and 14 
civilians. In addition to their regular 
weekday shifts, laboratory crews 
work night and weekend shifts to 
ensure fast processing of all orders. 

To staff its ophthalmic service 
units and the Ophthalmic Support 

and Training Activity, the Navy 
Medical Department operates a 
"C" school at the Yorktown facility 
for training optician-technicians. 
This program, recognized by the 
National Academy of Opticianry, 
consists of a 26- week course in all 
aspects of optical work. A typical 
student is a petty officer second 
class with five years of naval expe- 
rience, according to CAPT Testa. 
Most graduates remain on the York- 
town facility's staff. 

The Navy's ophthalmic program, 
begun when the Navy Appropriation 
Act of 1942 authorized funds for 
issuing spectacles to Navy and 
Marine Corps personnel serving 
abroad, has grown rapidly in recent 
years. "To do a good job in the mili- 
tary, one must have good vision," 
CAPT Testa says. "We're doing 
our job here to ensure that Armed 
Forces personnel who need cor- 
rected vision have it." 

Volume 68, June 1977 


UNIONS . . . Commanding officers are 
reminded that Department of Defense 
policy prohibits military members and 
civilian DOD employees from negoti- 
ating military service requirements with 
labor unions attempting to represent 
military personnel. A DOD policy state- 
ment advises that: 

No member of the Armed Forces, or civil- 
ian employee of the Department of Defense, 
may negotiate or bargain on behalf of the 
United States, with respect to terms and 
conditions of military service of members of 
the Armed Forces, with any individual, 
organization or association which represents 
or purports to represent members of the 
Armed Forces; nor may any member of the 
Armed Forces, or civilian employee of the 
Department of Defense, recognize any indi- 
vidual, organization or association for any 
such purpose. 

Members of the Armed Forces may 
join associations which run programs 
for their benefit, as long as the activities 
of such groups do not interfere with the 
lawful operation of the chain of com- 

BLOOD DONORS ... The Food and 
Drug Administration (FDA) has ruled 
that naval personnel assigned to ships 
deployed in areas endemic for malaria 
(listed in BUMED Instruction 6230. 11G) 
are eligible to donate blood six months 
after they return to a nonmalarial area, 

• they did not have a documented case 
of malaria during the deployment. 

• they have had no symptoms of the 

• they have not taken antimalarial 
drugs since their deployment. 

• they meet all other medical standards 
for blood donors, delineated in NAV- 
MED P-5120. 

The six-month waiting period is a 
change from the Navy's previous policy 
of requiring a three-year wait, and is the 
same waiting period usually required by 
civilian blood donor centers for people 
who have traveled to malarial areas. 
BUMED will ask the FDA to make the 
same change for shore-based personnel 
who have traveled in certain areas 
endemic for malaria. 

Navy members who have had malaria 
or have taken antimalarial prophylaxis 
are still not allowed to donate blood 
until three years after they become 
asymptomatic or after therapy ends. 
Even after three years, it is recom- 

mended that they not be used as blood 
donors if other donors are available, be- 
cause they may be harboring a dormant 
form of malaria. Malaria caused by 
Plasmodium vivax and Plasmodium 
ovale, for example, may remain seques- 
tered as long as four years, and disease 
due to Plasmodium malariae has re- 
mained dormant as long as 30 years. 


Medical Corps, Medical Service Corps 
and Nurse Corps officers of the inactive 
Reserve are urgently needed for Opera- 
tion Aestival Hiatus, scheduled for 
June, July and August 1977. This exer- 
cise gives inactive Reservists the oppor- 
tunity to train in their specialties while 
relieving critical manpower shortages at 
overtaxed Navy medical facilities. Va- 
cancies are available in the continental 
U.S. and overseas. 

All Reservists affiliated with the 
Medical Department are eligible to par- 
ticipate, regardless of their training/ 
pay category. Contact your Reserve 
Readiness Command medical programs 
officer for details. 

AWARDS . . . The Navy Awards System 
is designed to recognize individuals or 
units that have brought distinction upon 
themselves. When used properly, mili- 
tary awards and decorations can be an 
effective management tool, providing 
an incentive for greater effort and help- 
ing to build better morale. Injudicious 
use of awards, however, will destroy 
their basic value. 

Award recommendations that reach 
BUMED are reviewed by the BUMED 
Awards Review Committee. Committee 
members have observed that many 
recommendations are so full of trivia it 
is difficult to pick out the facts that 
justify the proposed award. 

The following few steps should help 
commands prepare clear, informative 
award recommendations: 

• First determine whether the event 
really deserves an award. Is some other 
type of recognition — a letter of com- 
mendation, for example — more appro- 

• Begin with a clear, concise statement 
of the event for which an award is rec- 
ommended ("HM1 Jones saved the life 
of a drowning child"). 

• In the next paragraphs, give specific 
details that substantiate the event. 

Where, when, and under what circum- 
stances did it occur? Who was involved? 
What happened? What benefits re- 

Recommendations written in short, 
clear sentences are the easiest to under- 
stand and have the best chance for ap- 

Commanding officers and others in- 
volved in the awards process should be 
totally familiar with Chapter 1 of the 
Awards Manual (SECNAV Instruction 
1650. IE). That manual contains detailed 
information on the philosophy of 
awards, the appropriate time for sub- 
mitting recommendations, acts which 
may deserve awards, and acts for which 
awards are inappropriate. 

patient rate for medical and dental care 
provided to civilian employees of the 
U.S. and their dependents in overseas 
Navy facilities increased on 1 April from 
$1 to $20 per diem. The $20 flat rate 
covers all outpatient medical services — 
including examinations, tests, diag- 
noses, treatment, prescriptions, evalua- 
tions and consultations — provided to a 
civilian during a single day. 

Certain follow-up visits will be 
covered by the $20 charged for the ini- 
tial visit. Also, some outpatient visits 
will be free: check-in at sick call to make 
an appointment, prescription refills, 
physical therapy treatments, and weight 
checks, for example. 

When immunizations are the only 
service provided, the charge will be $1 
per vaccination. However, if the patient 
is vaccinated as part of a visit for which 
a $20 charge is imposed, there is no ad- 
ditional charge for the immunization. 

For full details, see BUMED mes- 
sages P241833Z and 091414Z, which 
were sent to activities affected by the 


Hatten, Jr. (MSC) and LCDR Lee N. 
Hilling (MSC) have been named to the 
Secretariat of the new Department of 
Defense Health Council in the Office of 
the Assistant Secretary of Defense 
(Health Affairs). The Council was estab- 
lished in January by the Secretary of 
Defense to plan and evaluate military 
health care operations. As Secretariat 
members, the two management ana- 
lysts, formerly of BUMED, will provide 
administrative support to the Council 
and develop issue statements, pro- 
grams and reports for the Council to 
consider at monthly meetings. 


U.S. Navy Medicine 

IMAVMED Newsmakers 

Here's one from the small world 
department: Back in the early 
1960 's, CAPT Mary Conley (NC), 
then LT Mary Nester, was recruit- 
ing Navy nurses at universities and 
nursing schools in the Northeast, 
while Army Nurse Corps recruiter 
LTC Roberta Hawkins (then CAPT 
Roberta Scott) was prowling the 
same territory. The two nurses saw 
a lot of each other on tri-service 
recruiting visits and became 
friendly rivals. Tours completed, 
they went their separate ways. This 
year, when the Navy took over U.S. 
Army Hospital Okinawa, CAPT 
Conley was sent to Okinawa to take 
charge of the hospital's nursing 
service. Who should be on hand to 
greet her? LTC Hawkins, just 
finishing her tour as assistant chief 
of the nursing service. 

Leonardo, Rolando and Rodolfo 
Rodriguez have more than their last 
name in common — the three broth- 
ers, all hospital corpsmen, were 
recently promoted at the same time, 
Leonardo to HM1 and Rolando and 
Rodolfo to HM3. The brothers serve 
side by side at U.S. Naval Hospital 
Subic Bay, under the Navy's policy 
of assigning family members to the 
same duty station when possible. 

While the class of 1977 dozed 
through graduation speeches at 
Georgetown University Dental 
School, class president ENS Stuart 
Jones was halfway round the world 
— climbing Nanda Devi, a 25,645- 
foot mountain in the Himalayas. 
The 31-year-old graduate and his 
fellow climbers, who had been 
planning their assault on the remote 
peak for more than a year, left for 
India in early May, hoping at least 
one of them would reach the summit 
by 18 June. When ENS Jones 
returns, he'll take on a different 
kind of challenge: treating patients 
at Naval Regional Dental Center 
Camp Pendleton, Calif. 

Another Medical Department 
member also did some cliffhanging 
recently, although not for recrea- 
tion. HM3 David A. Vezina flew 
with a search and rescue helicopter 
team sent from Naval Air Station, 
Lemoore, Calif., to retrieve a climb- 
er stranded on a ledge in Yosemite 
National Park. As the pilot posi- 
tioned the aircraft in a hover 50 feet 
above the rescue site, HM3 Vezina 
rappelled down to the ledge. Find- 
ing the climber in good condition, 

Rodriguez brothers: All in the family 

Vezina tied himself and his patient 
to the helicopter's hoist and the two 
men were lifted to safety. It was 
the fifth rescue for the 22-year-old 
corpsman, a four-year Navy vet- 

Creative CDR Robert Jordan 

(MSC), staff physicist in the Nuclear 
Medicine Department at NRMC 
Oakland, has come up with a design 
for a more efficient, economical 
automobile engine. His newly pat- 
ented invention burns fuel more 
completely and produces less pollu- 
tion than most internal combustion 
engines. What's next on the draw- 
ing board? CDR Jordan hints at a 
portable, practical source of power 
for X-ray equipment. 

Conley & Hawkins: Small world 

HM3 Vezina: To the rescue 

Volume 68, June 1977 

On Duty 

Field Medical Service School: 

Combat Training That Works 

The instructors at the Field Medi- 
cal Service School (FMSS), Camp 
Pendleton, speak as if they're biting 
on bullets. 

"This exercise," says HM1 
Howard Huey, "can last as long as 
you'd like— and I don't think you 
want it to last very long. It gets cold 
up in the hills at night, and you're 
going to want to finish early, so let's 
get going." 

With those words, 163 hospital 
corpsmen begin a seven-mile march 
into the narrow, dusty canyons on 
the fringe of the Camp Pendleton 
Marine Corps base. Stuffed into 
camouflage utilities and wearing 
grim expressions, the men share 
nothing more than anonymity at this 

The situation changes when the 
class reaches the campsite and 
begins its military training exercise. 
For the next three days, instructors 
will coordinate and students will 
participate in war games designed 
to teach survival tactics, conceal- 
ment, camouflage, movement under 
Fire, map reading, communications, 
and mine and booby trap detection. 
"The students learn that they have 
to pull together and function as a 
unit," HM1 Huey says. "If they 
don't do it here, they won't do it in a 
combat situation, and people are 
going to die." 

According to ENS Stephen Van 
Zee (MSC), assistant training offi- 
cer, the five-week FMSS course 
prepares corpsmen to serve with 
Marine Corps combat units. "It's a 
simple enough goal," he says, "but 
we have problems achieving it. The 
physical conditioning is rough. We 
have to pack a lot of instruction into 
a short period of time." 


ENS Van Zee believes the biggest 
problem is trying to simulate a war- 
time situation in peacetime. "Most 
students know they're probably 
never going to see combat," he 
says. "Still, we have to prepare 
them for that possibility." 

Most FMSS instructors are Viet- 
nam combat veterans. ENS Van 

Field work includes crossing hostile ter- 
ritory (left) and treating a "patient's" 
emotional breakdown (above) 

Moving under fire to help wounded buddy is part of training exercises 

U.S. Navy Medicine 

Zee, a former corpsman and a Viet- 
nam veteran, believes the instruc- 
tors' Vietnam experience gives 
them an important frame of refer- 
ence the students lack. "We've 
treated combat casualties and real- 
ize how much the troops depend on 
us," he says. "In wartime, a corps- 
man is the greatest thing to come 
along since sliced bread." 

Pell-mell pace. The FMSS course 
has been taught eight times a year 
since 1950. The first class consisted 
of 80 corpsmen who had been re- 
called to active duty with Marine 
Corps Reserve units. That course 
lasted only two weeks. 

Today, in the four-week class- 
room phase, students learn Marine 
Corps uniform and grooming regu- 
lations, and command structure and 
function. Training continues with a 
tear gas demonstration and demon- 
strations of medical evacuation 
techniques, emergency first aid, 

tion, while others serve as corps- 
men and litter bearers. Roles are 
then switched to give each student 
an opportunity to use what he's 
learned in the classroom. 

Realism. The cries echoing 
through the canyons are part of the 
realism instructors hope the stu- 
dents will inject into the exercise. 
"Doc! Doc!" cries one man, hold- 
ing his leg and rocking from side to 
side. A corpsman decides the pa- 
tient's leg is broken and begins 
setting it. 

"I have a bleeder over here," 
another corpsman yells. "Get me 
some litter bearers." 

A different kind of crisis is taking 
place a few yards away: someone 
has had a nervous breakdown. His 
eyes are saucer-wide and he's 
screaming obscenities at the corps- 
men surrounding him. 

"Hold him down!" one corpsman 

Instructors explain combat tactics after students finish 7-mile hike 

cardiac care and treatment of shock 
and psychological casualties. Stu- 
dents also learn how to deal with 
fractures, burns, communicable dis- 
eases and poisoning. All are ex- 
pected to learn how to fire the .45- 
caliber pistol and M-16 assault rifle. 

The pell-mell pace — reveille is at 
0430 — leaves most students ex- 
hausted. "They don't have the 
strength to dwell on their com- 
plaints at the end of the day," ENS 
Van Zee says. 

During military training, students 
are divided into four teams. Some 
students man the battalion aid sta- 

"Take it easy, buddy," another 
says soothingly, trying to get a grip 
on the flailing patient. 

"He'll get a shot of Thorazine 
when the guys get him to the aid 
station," says a third student. 

"This is more like it," says an 
instructor surveying the scene. 
"Now the students are showing 
some interest in what they're 

"There's still a problem with 
levity, though," another instructor 
notes. "The students often enjoy 
the 'war games' so much that they 
forget what they're here for. Then 

we have to begin the whole exercise 
over again." 

Benefits. HMCS Craig Grothaus 
believes the FMSS course should be 
a requirement for all corpsmen. "Of 
course, we're at peace, and it's hard 
to simulate war with any degree of 
effectiveness," Chief Grothaus 
says. "But the number of combat 
casualties in Vietnam is proof that 
our training is necessary." 

"This program works," Chief 
Grothaus adds. "The men trained 
here survive, and their troops 
survive. I'm grateful if a student 
realizes that much." 

Other instructors report a keener 
sense of professionalism on the part 
of both teachers and students in 
recent classes. Why? "The instruc- 
tors are making the classes as inter- 
esting and informative as possible," 
explains HMC Homer Starr. "And 
the students are responding with 
more enthusiasm." 

The FMSS course has some 
fringe benefits. Students can reg- 
ister with Palomar Community Col- 
lege and earn six college credits by 
mastering emergency medical tech- 
niques. Another credit is available 
for passing the final physical fitness 
test. And, of course, there's the 
modest cachet a student acquires 
for qualifying as a combat-trained 

No women are enrolled at FMSS, 
although ENS Van Zee says, 
"We're ready for them. Plans have 
been made in case we receive per- 
mission from the Bureau of Medi- 
cine and Surgery to accept women." 

There are problems at FMSS, but 
only if you measure the actual pro- 
gram against the ideal. "It would be 
ideal if the classes could be smaller, 
so we could get to know each stu- 
dent personally," ENS Van Zee 
says. "It would be ideal if we could 
accept women today, and if all our 
students were highly motivated." 

"But we deal in realities," says 
ENS Van Zee, "and we have to 
capitalize on our strengths and 
weaknesses. It's a challenge for 
both instructors and students." 

— Story by J03 Glenn Amato. Photos by 
PH2 R. Weissleder and LCPL N. LaLuntas. 

Volume 68, June 1977 


Scholars' Scuttlebutt 

Reflections in the Wake: 
Two Decades of Navy Medicine 

CAPT Tor Richter, MC, USN 

The Service, the Service, 
you ought to join the Service. 
The Army, the Navy, 
at very generous pay. 

That stirring recruiting song was 
a show-stopper at the 1951 Aescula- 
pian Club extravaganza. Its lyrics, 
and especially its percussive climax 
— Da Dum Di Dum Di Dum — gave 
lighthearted if heavyhanded expres- 
sion to a truth as enduring as most 
anything else we were taught 
during those four years: military 
medicine is not every Harvard grad- 
uate's cup of tea. Well, first- 
nighters, here it is 25 years later, 
and a few of us marched off to a dif- 
ferent drummer. Surely you will not 
expect a cautious bureaucrat — "full 
of high sentence but a bit obtuse" — 
to attempt anything offhandedly 
cosmic. A few "sea stories," per- 
haps, ventured less for their intrin- 
sic interest than for the parallels 
they may call up in your own experi- 
ence. No pearls, then, but with luck 
maybe a few grains of sand. 

One generally thinks of the mili- 
tary in terms of uniformity and 
interchangeability of parts. For the 
physician, nothing could be farther 
from the truth. My career as a Navy 
doctor has been typical only in its 
variety. I have had a mixture of 
clinical, administrative and opera- 
tional assignments. In peacetime, 
naval hospitals are similar to civil- 
ian hospitals. And of my adminis- 
trative duties the less said the 

CAPT Richter is commanding officer of 
Naval Regional Medical Center Camp Le- 
jeune. N.C. 28542. This article first appeared 
in the Harvard Medical Alumni Bulletin [50 
(6): 18-19, July/ August 1976], and is re- 
printed with permission. 

better. I will speak of my experi- 
ences in operational medicine. 

A medical officer assigned to 
operational duty quickly acquires an 
altered perception of the concept of 
the fitness of the environment. Sail- 
ors and Marines experience adverse 
environments far beyond those en- 
countered by all but a small number 
of adventurous civilians. Heat and 
cold, wind and wave, height and 
depth, noxious creatures great and 

Not only are military environ- 
ments severe and unforgiving, but 
they lack the potential of being 
brought under control that is com- 
mon in civilian life. Thus the farmer 
can rid his stable of rats, his fields 
of venomous snakes. He will heat 
his house and find safe water. An 
invading force crossing those fields 
or occupying that house does not 
have the luxury, at least for a time, 
of environmental control. Therefore 
in the military the emphasis must 
be on individual protection, rather 
than on what by contrast might be 
termed the public health approach 
to the prevention of disease or 
injury. What used to seem to me the 
maniacal interest of the Armed 
Forces in immunization is a mani- 
festation of this phenomenon. 

Yet these adverse environments, 
like other adversities, have their 
sweet uses as well. They represent 
workings of nature apart from the 
beaten path no less than do rare 
diseases or genes gone astray. Here 
also we may expect to find clues 
that clarify normal physiology and 

A simple example from diving 
physiology — the diving injury 
known as "squeeze" — may help 

illustrate this. Everyone who has 
dived even in a moderately deep 
pool knows that you must equalize 
the pressure in your ears and 
sinuses in order to avoid pain and 
injury. Naturally the air to do this 
comes from that already in the 
lungs. Unless one has a scuba tank 
or an air hose, this gas supply is 
limited to whatever was inhaled 
prior to the dive. The "obvious" 
prediction then is that the depth 
limit of breath-holding diving is 
determined by the ratio of gas in the 
lungs to that in the rigid air-contain- 
ing chambers such as the middle 
ear, trachea and sinuses. This ratio 
is roughly five to one, which trans- 
lates as a breath-hold diving limit of 
five atmospheres absolute or 165 
feet. In actuality, dives to depths 
greater than 240 feet have been 
reliably documented. Though the 
average Navy diver is sometimes 
credited with wearing a size 52 coat 
and a size 6 hat, we know that other 
factors must be at work. There is 
during breath-hold diving an in- 
trathoracic shift of blood which 
greatly reduces the residual vol- 
ume. In short, a human under these 
conditions behaves rather more like 
a diving mammal than we would 
have thought when we heard Don 
Fawcett describe the dugong and 
manatee a few years back. 

The Navy is currently sending 
more of its medical officers on brief 
tours to sea than it formerly did. 
This practice has met with some re- 
sistance, particularly from special- 
ists whose experience has been 
limited to hospitals, and who regard 
shipboard assignment both as a 
waste of their specialty training and 
as potentially threatening if condi- 


U.S. Navy Medicine 

Medical officers make ward rounds aboard USS Kitty Hawk 

tions outside their specialty present. 
Those who have completed sea 
tours, though, have usually been 
glad they went. 

There are several reasons for 
this. The fascination of the sea and 
ships is one. The old prescription of 
a sea change is good for the doctor, 
too. On a man of war, there is the 
fascination which familiarity does 
not diminish in watching complex 
and dangerous evolutions such as 
carrier landings and missile launch- 
ings. The physician assigned to sea 
duty learns a lot in a hurry, though 
most of his new knowledge is not 
medical in the narrow sense. Never- 
theless, medical training permits a 
view of the ship and its operations 
that is unique to the medical officer, 
and with experience he becomes an 
active participant rather than a 
mere passenger. He ranges far from 
his sick-bay to inspect the ship, and 
to participate in emergency drills 
and occasionally in real emergen- 
cies . He comes to see the ship as the 
site of a thousand potential acci- 
dents. Everywhere there is stored 
potential energy, pressurized 
flasks, taut lines, unburned fuel. 
Accident and even disaster preven- 
tion are a matter of constant prepa- 
ration and training. In shipboard 
safety there are even quasi- philo- 
sophical issues such as the amount 
of time and equipment allocated to 
preparing for various contingencies. 
American submarine commanders, 
for example, give very little atten- 
tion to escape from sunken sub- 
marines. Instead, they concentrate 

on keeping the submarine from 

The Navy clinician who spends 
even a short time at sea will better 
be able to do his job when he re- 
turns ashore, for he gains a far 
better idea of the work environment 
from which his active-duty patients 
come and to which they return. 
More than one sailor has appeared 
at the quarterdeck of his ship, "Full 
duty, fit for same," in a long leg 

Even the most cerebral specialist 
can enjoy and profit by this sort of 
practical sabbatical. One of the 
Brigham surgeons — I think it may 
have been Professor Moore himself 
— had an aphorism that there was 
no such thing as minor surgery, 
only minor surgeons. So it is also 
with shipboard medicine. 

And there is another more gen- 
eral sense in which a hospital based 
military doctor can gain refresh- 
ment and even inspiration from 
working directly with the operating 
forces. He really sees what the Navy 
does. It is a particularly good anti- 
dote to the disillusionment which 
may come from daily reading about 
national indecision and lack of 
direction. Best fun of all is to talk to 
the young men who speak with 
shining eyes about their respective 
crafts. Lives depend on them. They 
are good and they know it. But for 
the Navy, they might be parking 
cars and pumping gas looking for 
that way back to San Jose. 

Operational medicine then, be- 
sides being necessary, is educa- 

tional and stimulating. Few make 
an entire career of it, though. For 
most, an early operational tour is 
followed by further training, clinical 
or research duties, and if fate dic- 
tates, those administrative posts 
euphemistically called positions of 
leadership. A Navy career thus 
tends to converge with civilian 
medicine. The senior Navy physi- 
cian, like many of you, approaches 
his work wondering if he is twisting 
the right knobs or indeed if the 
knobs are hooked up to anything. 
One becomes reflective, and even 
reflects on reflections. 

One of the first things that hap- 
pened to me after I came into the 
Navy was to be interviewed by 
Admiral Rickover. These interviews 
were conducted in an atmosphere of 
seriousness which in retrospect 
seems comic. Most of the things 
Admiral Rickover said to the inter- 
viewee were not intended to put him 
at his ease. One of the first remarks 
he made to me that day was, 
"Richter, joining the Navy Medical 
Corps is like joining a last-place ball 
club." I am sure now that he was 
putting me on, but I took him liter- 
ally at the time, and an animated 
discussion followed. I find that even 
now I cannot think about that ex- 
change without a certain amount of 
heat — maybe because he touched 
on something that could so easily be 
true. The Navy medical officer, with 
his variety of assignments, is at risk 
of becoming a dilettante. Frequent 
rotations of assignment diffuse re- 
sponsibility, and where many are 
responsible, none may be in charge. 
Finally, the Navy needs identity 
without parochialism. This chronic 
problem has become acute with the 
end of the doctor draft and depend- 
ence on volunteers. We miss the 
leavening young physicians bring 
from civilian life and the under- 
standing they take back with them 
on their return. Most of all, we face 
the difficult task of maintaining 
quality among our volunteers. 

I hope George Murphy and the 
other Aesculapians have kept their 
voices in tune. It may soon be time 
for another chorus. 

Volume 68, June 1977 



Safety Tips 

Safety in Anesthetizing Areas 

The National Fire Protection 'Association (NFPA) 
standard, Inhalation Anesthetics (NFPA 56A), last 
issued in 1973 and now being revised, outlines safety 
requirements for hospital anesthetizing locations. 
Terms used in the standard are: 

Anesthetizing location: Any area of a hospital in 
which it is intended to administer any flammable or 
nonflammable inhalation anesthetic agents in the 
course of examination or treatment. These areas in- 
clude operating, delivery, emergency, anesthesia and 
utility rooms, as well as corridors and other areas used 
for induction of anesthesia with flammable or nonflam- 
mable anesthetizing agents. 

Nonflammable anesthetizing location: Any operat- 
ing, delivery, anesthesia induction, emergency, treat- 
ment, or other area permanently used for, or intended 
for the exclusive use of, nonflammable anesthetics. 

Flammable anesthetizing location: Any room or area 
used or intended for the use of flammable anesthetics. 

The Bureau of Medicine and Surgery determines 
these areas in the design of Navy medical facilities. 
BUMED Instruction 5100.5A of 5 Sept 1974 prohibits 
the use of flammable anesthetics in all Navy medical 
facilities except graduate teaching hospitals, which 
must maintain at least one area for training staff mem- 
bers in the use of flammable anesthetics. 

The requirements of the NFPA standard on inhala- 
tion anesthetics are summarized below: 

Humidity and air: In anesthetizing areas, humidity 
must be at least 50% for temperatures between 5°F 
and 70°F. (The Joint Commission on Accreditation of 
Hospitals requires that the humidity in each operating 
room be recorded daily.) In flammable anesthetizing 
locations, humidity provides a conductive path — be- 
cause carbon dioxide in the air combined with water 
produces carbonic acid — to dissipate static charges. In 
nonflammable anesthetizing locations, humidity is be- 
lieved to control airborne bacteria. 

In the current edition of NFPA 56A, there are no re- 
quirements regarding the amount of air that must be 
maintained in anesthetizing areas, but the appendix 
recommends that the total volume of air in the room be 
changed 25 times per hour, to help dilute any bacteria 
that people bring into the room. The appendix also 
recommends that positive pressure be used in the 
operating room to prevent airborne bacteria from enter- 
ing the room; no pressure differentials are suggested. 
(Appendix information is advisory, not mandatory.) 


Gas storage: Medical gases should be stored in racks 
or fastenings to prevent accidental damage of gas con- 
tainers. Oxidizing gases such as oxygen and nitrous 
oxide should be stored separate from flammable gases. 

Gas pipeline systems: NFPA 56F, Standard for Non- 
flammable Medical Gas Systems, advises that an acces- 
sible, clearly identified shutoff valve should be located 
outside each anesthetizing location, to be used in 
emergencies; however, each connection in the system 
must use a non-interchangeable coupling. For threaded 
connections, the standard is Diameter Index Safety 
System, Compressed Gas Association Pamphlet V-5. 
For cylinder valve outlet connections, the standard is 
American National Standard ANSI B57. 1-1965. No 
piping systems shall be used for flammable gases. 

Electrical distribution system: The anesthetizing 
area must have a local ungrounded or isolated electrical 
system, consisting of an isolation transformer and a line 
isolation transformer. The isolation transformer helps 
prevent electrocutions that might occur because floors 
are required to be conductive. The isolated system also 
prevents micro-shock (ventricular fibrillation stimu- 
lated by micro-amperes of current applied to the heart), 
if equipment is adequately grounded. The isolated 
system gives some protection from electrical injuries 
that can occur in wet areas, which are common in emer- 
gency rooms. This system also maintains continuous 
electrical service with a line-to-ground fault, and makes 
it easier for workers to assess the condition of equip- 

Equipotential grounding system: NFPA 56A requires 
an equipotential grounding system for all hospitals. 
Electric current cannot flow without a voltage; there- 
fore, no current can flow through a patient if an anes- 
thetizing area has no potential (voltage difference). The 
equipotential grounding system must be maintained in 
accordance with NFPA 56 A. 

Grounding jacks and plugs: The standard prescribes 
types of grounding devices to be used. All conductive 
surfaces — even those not electrically powered — must 
be grounded. For example, back tables, anesthesia 
machines, and mayo stands must be grounded. 

Receptacles and plugs: In flammable anesthetizing 
areas, explosion-proof plugs listed for the purpose are 
required; "listed for the purpose" means that a testing 
organization, such as Underwriters Laboratories or 
Factory Mutual, has tested and approved samples of 
the item. For nonflammable locations, the three-con- 

U.S. Navy Medicine 

ductor, twist lock plug is required. The National Electri- 
cal Code (NFPA 70) allows the three-prong, U-ground 
type of plug that is listed for the purpose to be used in 
flammable anesthetizing locations. 

Lighting: Current for ceiling-suspended Fixtures, 
such as operating room lights, must be supplied from 
isolation transformers so that people who touch the 
light will be protected from electric shock. Lights for 
general illumination can be attached to the normal 
grounded electricity supply. 

Portable electric equipment: To be safe, portable 
equipment must operate at eight volts or less, be mois- 
ture resistant, and have double insulation. Power must 
be supplied by an isolation transformer or battery. 

Administration and maintenance: Everyone who 
works in anesthetizing locations must understand the 
hazards of using anesthetics. Licensing and other hos- 
pital approval organizations should look for compliance 
with NFPA requirements when inspecting facilities. 

Appendix B of NFPA 56A includes three sets of 
proposed regulations that apply to flammable, non- 
flammable, and mixed anesthetizing locations. Safe 
methods for handling gases, cylinders, electrical 
systems, and anesthetizing equipment are also de- 
scribed in this appendix. 

This discussion has covered the basic requirements 
in NFPA 56A which pertain to all anesthetizing loca- 
tions. In the next issue of U.S. Navy Medicine, there 
will be a summary of the NFPA's specific requirements 
for flammable, nonflammable and mixed anesthetizing 

Disposing of Health and 
Dental Records 

Health and dental records of Marines whose active 
duty is terminated on or after 1 July 1977 will now be 
closed and delivered immediately to the command 
maintaining the member's service record or officer 
qualification record. 

This change, which will be described in Change 91 to 
the Manual of the Medical Department, is the sixth and 
final phase of the Master Medical Record Concept. 
Under that concept, each member of the naval service 
has only one health and dental record which, when the 
person is separated from active duty, is combined with 
his or her service record. 

In the first phase of master medical record imple- 
mentation, medical and dental information which had 
been maintained at BUMED on active-duty Navy and 
Marine Corps personnel was returned to each mem- 
ber's command to be incorporated in the member's 
health and dental record. 

In Phase II, medical and dental records held in BU- 

MED on inactive Navy reservists were forwarded to the 
Naval Reserve Personnel Center in New Orleans; 
records of drilling reservists went to their commands 
for incorporation into their health and dental records. 

Phase III provided for the health and dental records 
of Navy personnel whose active duty ended after 30 
June 1976 to be closed and sent to the command main- 
taining the service record. 

In Phase IV, medical and dental information on Class 
II drilling Marine reservists was forwarded to their 
commands for incorporation into their health and dental 

Phase V provided for health and dental records held 
by BUMED on Class III inactive Marine reservists to be 
sent to the Marine Corps Reserve Forces Administra- 
tive Activity in Kansas City, Mo. 

After Phase VI is completed on 1 July, health and 
dental records of Navy and Marine Corps personnel 
who leave active duty will all be disposed of in the same 
way: the records will be closed out and placed perma- 
nently in the member's service record. 

All naval commands holding health and dental 
records of Navy and Marine Corps personnel should 
disseminate the above information widely, and ensure 
that record keepers are aware of and comply with the 
provisions of Change 91 to the Manual of the Medical 

Mass Screening for 
Blood Donor Eligibility 

Mass screening of individuals to determine their 
eligibility as blood donors has been used successfully at 
many naval blood donor centers. This practice is ac- 
ceptable provided: 

• the interviewer explains each question concerning 
prospective donors' medical histories. 

• time is allowed for the potential donors to answer 
questions accurately on the medical history form and to 
ask any questions they may have. 

• final determination of suitability is made separately 
for each individual, in a semiprivate atmosphere, by 
qualified Medical Department personnel. 

Most questions about medical history on the Donor 
Record (DD Form 572) can be answered only by the in- 
dividual. One exception may be recruits, who are often 
confused about the type of immunizations they received 
during training and the dates they were immunized. 
The donor center supervisor is responsible for ascer- 
taining from the recruit command, on the day blood is 
donated, the kind and dates of inoculations received by 
a group of recruit donors. However, information re- 
ceived from the recruit command cannot substitute for 
information obtained through personal donor screen- 
ing, because individual differences can exist. 

Volume 68, June 1977 


Notes S Announcements 


The Hospital Corps urgently needs applicants for the 
following "C" school courses: Nuclear Submarine 
Medicine Technic (HM-8402), Nuclear Medicine Tech- 
nic (HM-8407), Aviation Physiology Technic (HM- 
8409), Advanced Hospital Corps School (HM-8425), 
Otolaryngology Technic (HM-8446), (Basic) Biomedical 
Equipment Repair (HM-8477), Operating Room Tech- 
nic (HM-8483), Neuropsychiatry Technic (HM-8485), 
Special Operations Technic (HM-8492), and Medical 
Deep Sea Diving Technic (HM-8493). 

Applicants must be qualified for assignment to "C" 
school training. For further information, contact the 
"C" Schools Coordinator, Bureau of Medicine and 
Surgery (Code 34), Navy Department, Washington, 
D.C. 20372, Autovon 294-4682. 


The following courses for Navy nurses (in addition to 
those announced in U.S. Navy Medicine, April 1977) 
will be given at Naval Regional Medical Center Ports- 
mouth, Va. in 1978. For further information, contact 
LCDR Shirlee C. Hicks, NC, USN, Educational Coordi- 
nator, NRMC Portsmouth, Va. 23708. 

30 Jamiary-17 February 

20-31 March 

Coronary care workshop for nurses 
(90 contact hours) 
Critical care workshop for nurses 
(60 hours) 


Navy physicians serving in operational or manage- 
rial billets may now apply for a short clinical residency 
to renew skills before starting a more comprehensive 
clinical assignment, under a new program announced 
in BUMED Notice 1520 of 11 March 1977. 

The period of training (not to exceed 20 weeks) and 
the content of each abbreviated residency will be 
tailored to the needs of the physician. Training will be 
in facilities that can provide the required clinical ex- 
perience in the least possible time at the least ex- 
pense — usually Navy graduate medical training centers 
and regional medical centers. Such training will nor- 
mally be accomplished in association with a permanent 
change of station move. 

To ask for an abbreviated clinical residency assign- 
ment, medical officers must submit a letter explaining 
why they want the training and what professional 
benefits they expect to gain from it. Requests must be 
submitted to BUMED (Code 0011) early enough to 

allow time for selection of a training site and for the 
physician and his preceptor to plan a suitable program. 
The commanding officer of the training facility will as- 
sign the director of clinical services or an equally quali- 
fied physician as preceptor. When a medical officer 
completes the abbreviated residency, the commanding 
officer will send a letter describing the physician's 
accomplishments to BUMED (Code 0011). Each abbre- 
viated clinical residency may be evaluated for possible 
continuing education credit. 


Reservists who want retirement point credit for at- 
tending professional meetings should refer to BUPERS 
Manual, Article 6610260 and DOD Directive 1215.7 of 
19 Dec 1974. These references indicate that retirement 
point credit may be given to a Reservist for attending a 
professional meeting only when the meeting will aid his 
professional development and prepare him for mobili- 
zation assignments. The meeting must occupy at least 
two hours a day and last no longer than five days. The 
value of a meeting is determined by the Chief, Bureau 
of Medicine and Surgery. The meeting's content and 
objectives must relate clearly to the Reservist's mobili- 
zation assignment, designator, and clinical specialty. 

Authorization for retirement point credit must be 
obtained before the meeting. Requests, including a 
copy of the agenda, must be forwarded 30 days in ad- 
vance to the Chief, Bureau of Medicine and Surgery 
(Code 36), Navy Department, Washington, D.C. 20372. 
Once a meeting has been approved, it is approved for 
all Reservists in the appropriate designator and 


Active-duty personnel can now compute their retired 
pay easily by using new information contained in 
change 1 to BUPERS Instruction 7220.27. 

The change describes years of service creditable for 
multiplier and basic pay purposes. Individuals can 
compute their retired pay for key dates in their career, 
and compare past and present pay rates. 

Under retired pay inversion legislation passed last 
year, individuals may not receive less retired or 
retainer pay than they would have received if they had 
retired at an earlier date. By following the computation 
process described in the revised instruction, military 
men and women will be able to determine the highest 
pay they were eligible to receive at any time during 
their career. 

The revised instruction also contains the latest basic 
pay tables and current consumer price index adjust- 


U.S. Navy Medicine 


The Mysteries 

of Sleep 

Laverne C. Johnson, Ph.D. 


• ^ ^V 

FIGURE 1. Subject wired for an all-night sleep study at the 
Naval Health Research Center sleep laboratory. 

How much sleep do we need? Is deep sleep better 
than catnaps or dozing? How long can we go without 
sleep? Must we get our sleep in a single chunk or can 
we take it in "three square naps" a day? These ques- 
tions have been keeping staff members at the Psycho- 
physiology Division, Naval Health Research Center, 
San Diego, awake at night. 


In the past 20 years, there has been a dramatic in- 
crease in research on the one-third of our lives most of 
us spend sleeping. One consistent finding: sleep is not 
a quiet period, nor is it a period of unconsciousness. 
Sleep has its own unique pattern of physiological, bio- 
chemical, hormonal and mental activity. 

Consider the electrical activity of the brain. Electro- 
encephalographic (EEG) studies show that sleepers' 
brain patterns vary from the low-amplitude brain-wave 
patterns of sleep onset to the high-amplitude delta (1 
Hertz) waves of deep or "slow-wave" sleep. Rapid eye 
movements (REMs) during sleep are associated with a 
low-amplitude EEG pattern very much like the pattern 
seen during sleep onset (1,2). During this REM stage of 
sleep, the subject is most likely to dream, although 
dreamlike mental activity occurs in all sleep stages, (It 
was the belief that they had identified dreaming, the 
royal road to the unconscious, that sparked much of the 
enthusiasm of early sleep researchers.) 

When subjects are wired for sleep recordings (Figure 
1), EEG patterns typical of the five sleep stages are 
seen (Figure 2). These clearly defined EEG patterns 
dispelled the belief that sleep was a homogeneous state 
which varied only in depth. Instead, during sleep a 
person goes through a regular pattern, as shown in the 
sleep profiles of two subjects (Figure 3). Each subject 
begins with stage 1, goes on to stages 2, 3 and 4, then 
back to stage 2. From 90 to 100 minutes after sleep on- 

Dr. Johnson is head of the Psychophysiology Division at the Naval 
Health Research Center, San Diego, Calif. 92152. He is also asso- 
ciated with San Diego State University and the University of Califor- 
nia at San Diego. 

Volume 68, June 1977 



F3 - A"V*~V-^ ■"haaiA.wW^.hvh^ 

■'. "*h**-s*. w^-V^v^ >W. 


"I vyjtfWj ;,,V^'Av,v.', , . 1 " t „ 


w* 'j-- 



FIGURE 2. Electroencephalograph readings show a subject 
awake (W) and in five stages of sleep: 1, REM, 2, 3, and 4. 
Each reading covers about 20 seconds. LEOG and REOG 
mean left and right electroculogram referenced to mastoid. 
F3-A, C3-A and 01-A indicate (respectively) left frontal, cen- 
tral, and occipital electrode referenced to mastoid. 









3 4 5 


FIGURE 3. All-night sleep profiles of two young adult males. 
The subject of the upper profile went to sleep at 2200, while 
the subject of the lower reading began sleeping near mid- 


set, the subject usually goes from stage 2 to stage 
REM. With slight ups and downs, the subject then 
returns to stage 2, possibly goes on to stage 3, back to 
2, then again to REM with a return to stage 2. (Ordi- 
narily, a normal, healthy subject enters a REM period 
only from stage 2.) Periods of slow- wave sleep (stages 3 
and 4) usually disappear as sleep continues, until 
during the last part of a night's sleep stage 2 alternates 
with REM. 

Whether people go to bed at 2200 or 0200, they follow 
the same cycle. Night workers also follow this cycle 
during daytime sleep. The average young adult spends 
6% of his or her sleep time in stage 1, 50% in stage 2, 
7% in stage 3, 16% in stage 4, and 20% in stage REM. 
About 1% of sleep time is occupied by body move- 
ments. As people grow older, the sleep time they spend 
in stage 4 decreases until after age 60 stage 4 may be 
absent; other sleep stages do not change as dramati- 
cally with increasing age. There are no major differ- 
ences between males and females in total sleep time or 
pattern of sleep. 

In the early days of sleep research, some scientists 
believed that adequate amounts of REM sleep, with its 
vivid dreams, are crucial for emotional health. Others 
believed that stages 3 and 4 (slow -wave sleep) are 
necessary for sleep to be restorative. Research in our 
laboratory (3,4,5) as well as in other sleep centers has 
shown that neither belief is correct: there are no firm 
data to show that the amount of time spent in REM or in 
slow-wave sleep affects behavior or performance when 
an individual is awake. The significance of sleep stages 
remains an unsolved mystery. 


The total amount of sleep appears to be the most 
important factor affecting awake behavior and perform- 
ance. When we asked 750 students at the Naval School 
of Health Sciences, San Diego, how long they sleep, the 
most obvious difference was the wide variations in the 
amount of sleep reported. A preliminary analysis of our 
survey also suggests that sleep lengths of these Navy 
students are shorter than students' sleep lengths re- 
ported by Webb (6) at the University of Florida. Of 
more than 4,000 students entering the University, 7% 
said they slept less than 6Vi hours each night and 3% 
reported more than 9Vi hours each night; most 
students slept between 7 and 8 hours. Thirty-five 
percent of the naval students said that on workdays 
they usually slept less than 6V2 hours; less than 1% 
slept more than 9Vi hours on workdays. On weekends, 
12% reported sleeping less than 6V2 hours, but 22% 
slept more than 10 hours to make up for sleep lost 
during the week. 

The easiest way for people to tell whether they are 
getting enough sleep is to note their sleep habits and 
their condition after waking. If someone needs an alarm 
clock to wake up, tends to doze off shortly after getting 





Ping' B 

2 4 6 8 10 12 4 16 

Hours of Uninterrupted Sleep 

FIGURE 4. Profiles show periods of uninterrupted sleep for 
crewmembers aboard the USS Tucker, USS Roark and USS 
Kitty Hawk, and among shore-based personnel ('Ping' B). 


U.S. Navy Medicine 

up, or falls asleep during lectures, conversations, or 
reading— and if there are no contributing health prob- 
lems — he or she probably needs more sleep. 

While regular sleep habits do not necessarily ensure 
an adequate amount of sleep, irregular sleep habits 
almost always lead to a sleep debt, and may cause dis- 
orders in chemical and physiological rhythms which are 
normally on a 24-hour schedule. In the Navy it is diffi- 
cult to maintain a regular sleeping schedule during 
shipboard watch schedules. About three years ago, 
Paul Naitoh, Ph.D., a psychologist on our staff, 
compared sleep schedules aboard the carrier USS Kitty 
Hawk and the destroyers USS Tucker and USS Roark 
with the sleep of men in land-based barracks (called 
'Ping' B in the study). Under 'Ping' B conditions, 75% 
of the men's sleep was uninterrupted for 6 to 9'/s hours, 
and the group's sleep pattern was symmetrical (Figure 
4). But shipboard sleep differed considerably: only 
about 30% to 35% of the crew obtained 6 to 9 hours of 
uninterrupted sleep, while approximately 50% of the 
crew got less than 4 hours of uninterrupted sleep. 

Even more striking was the disruption of the sleep/ 
wake cycle in shipboard sleep (Figure 5). Most of us 
prefer a schedule of 8 hours of sleep followed by 16 
hours awake. 'Ping' B conditions reflect this prefer- 
ence, with most subjects reporting 16 to 18 hours 
between sleep periods. Again, shipboard sleep was 
dramatically different: the sleep/wake cycle was clearly 
fragmented, with the time between sleep ranging from 
1 to 22 hours. 

Do these disruptions in sleep patterns affect the 
crew's performance and health? In a study of carrier 
flight operations during the Vietnam War, Brictson and 
associates (7) found that the more fragmented the 
sleep/wake schedule, the worse the carrier landing 
performance. However, the total amount of sleep ob- 
tained over each 24-hour period was not significantly 
associated with landing performance. 


People often tell me that they could get more out of 
life if they didn't sleep so much, and ask, "Can I reduce 
my sleep?" The answer is yes— but it's not easy, and 
abrupt reductions in sleep time usually do not last. 
When the immediate need to reduce sleep passes, most 
people return to their former sleep schedule. However, 
when sleep is reduced gradually the change tends to 

When the Naval Health Research Center collaborated 
with the Psychiatry Department of the University of 
California, Irvine, on a sleep reduction study, we ob- 
served gradual sleep reduction in three couples who 
customarily slept 8 hours, and in one couple who slept 
6V2 hours a night. Each subject was asked to reduce his 
or her sleep by 30 minutes every three or four weeks, 
with the Final amount of sleep reduction left for the 
subjects to determine based on their feelings and 

Volume 68, June 1977 

awake performance. Sleep was monitored by logs each 
subject kept and by recordings of EEG activity. 

Among the 8-hour sleepers, two subjects reduced 
their sleep to AVi hours, two to 5 hours, and two to SVi 
hours. The two 6V2-hour subjects stopped reducing 
their sleep time at 5 hours. All subjects said that fatigue 
and difficulty in getting up were their main reasons for 
stopping, even when awake performance was not seri- 
ously impaired. At the end of a follow-up year, all 
subjects were sleeping at least one hour less than 


«- 20 " 

t 15- 






t 15 







t 15- 









\ P l l 

Kilty Hawk 


Hours Since Las 

FIGURE 5. Profiles of shipboard and 'Ping' B sleep/wake 
cycles reflect fragmentation of shipboard sleep. 


before the study and two subjects were sleeping two 
hours less. Mood and feelings of fatigue had returned 
to pre-study levels, even though sleep was reduced. 
The 6Vj-hour couple returned to their customary 
routine during follow-up, indicating that 6V2 hours was 
their minimal sleep time. 

These results suggest that some of us can function 
well on less sleep. But would it be worth the effort? For 
a lasting change, our sleep/wake cycle requires a grad- 
ual shift that allows our biological rhythms to adjust 
gradually. As noted earlier, if people feel fatigued and 
have trouble getting up, if they find themselves falling 
asleep easily during the day, and if it is hard for them to 
stay awake in the evening, they probably need more 
sleep. Further sleep reduction would not be wise. 


How long can we go with no sleep at all? This 
question faces many commanding officers and people 
in charge of special military operations who must plan 
the logistics of sleep as carefully as they plan for food, 
ammunition, and other essentials (8). 

Marshall (9) described the effects of sleep deficit and 
fatigue on paratroopers in the 1944 invasion of Nor- 

They were dull-eyed, bodily worn and too tired to think connected- 
ly. Even a 30-minute flop on the turf with the stars for a blanket would 
have doubled the power of this body and quickened the minds of its 
leaders to ideas which they had blanked out. But no one thought to 
take that precaution. The United States Army is indifferent toward 
common-sense rules by which the energy of men may be conserved in 
combat. . . . Said Captain Patch of his people on the far right, "They 
were so beat that they could not understand words even if an order 
was clearly expressed. I was too tired to talk straight. Nothing I heard 
made a firm impression on me. I spoke jerkily in phrases because 1 
could not remember the thoughts which had preceded what I said." 

The operational consequences for air crews of sleep 
deprivation and deficit have been discussed by Johnson 
and Naitoh (10); Woodward and Nelson of the Office of 
Naval Research have reviewed the literature on effects 
of sleep loss and work-rest schedules on performance 
(11). These two reports conclude that total sleep loss of 
more than 60 hours produces neurological, physiologi- 
cal, biochemical, performance, behavioral, and mood 
changes. While the degree of change depends on the 
individual, changes become evident in all areas as sleep 
loss goes beyond 60 hours. 

One subject in our laboratory endured a sleep loss 
of 264 hours, and recovered completely after three 
nights of sleep (12). In most operational schedules, 
crewmembers would probably lose no more than 40 to 
48 hours of sleep, with a 30 to 36 hour loss more likely. 
Such amounts can be tolerated without debilitating 
physiological changes. 

Effects of sleep loss show first in mood changes and 
greater fatigue. Performance changes are minimal if 
tasks are brief, self-paced and highly motivating, and if 
the worker is given some idea of the adequacy of his 

„-"" „,-'*" Interpolation trom 

.-- ,,---" clinical studies of 

,.-'' acule sleep less 

2-3 day recovery for 72 hour continuous operation 

12 — 14 hour recovery tor 35 — 43 hour continuous operation 

12 hour recovery (or 24 hour continuous operation 
Normal work day 

J i t . 1 . i . L- 

12 24 36 

72 B4 96 108 120 132 14 


FIGURE 6. As hours of sleep loss increase, so do hours of 
recovery sleep needed. The dotted lines indicate that the 
variability of this ratio (hours of sleep/hours of recovery sleep 
required) also increases as the subject loses more sleep. 
(From Woodward and Nelson, 11) 

performance. People performing tasks that require 
sustained vigilance and attention, use of newly 
acquired skills, retention of new information, and a 
long time to complete are more likely to show sleep-loss 
effects. Most of the decrement in performance will 
occur during brief periods of "microsleep" which occur 
as the person is working. These effects are more likely 
to occur in the early morning, when body temperature 
is low. 

To minimize such effects, work should be reduced 
during hours when sleep would normally occur, regard- 
less of the actual time of day. For example, travel in jets 
often results in duty schedules falling at times when 
one would normally be asleep. This "jet lag" effect and 
its relation to sleep loss must be taken into account in 
setting duty schedules. 

After 36 hours of continuous duty, how much recov- 
ery sleep is required? Based on current research and 
operational data, Woodward and Nelson (//) have pro- 
vided a useful guide for estimating recovery sleep times 
(Figure 6). For example if a man's duty results in 36 
cumulative hours of sleep loss, he could find the recom- 
mended hours of recovery by noting the point on the 
guide where 36 hours of sleep loss (see vertical axis) 
intersects the solid line. Then, he would draw a vertical 
line from that point to the horizontal "hours of recov- 
ery" scale. For 36 hours of sleep loss, 18 hours of re- 
covery are recommended. For 72 hours of sleep loss, 60 
recovery hours are recommended. After 36 or 72 hours 
of sleep loss, it is highly unlikely that anyone would 
spend all of the recovery time in continuous sleep, The 
young man who was awake for 264 hours in our labora- 
tory slept only 15 hours before awakening. 

The Naval Health Research Center's psychophysiol- 
ogy laboratory is conducting a study of poor sleepers. 
We also plan to continue studying variations in sleep 


U.S. Navy Medicine 

schedules, with particular attention to determining the 
optimal wake-sleep schedule for effective performance 
after varying periods of sleep loss. Our results so far 
suggest that required sleep lengths and sleep 
schedules are flexible and can be adapted to a changed 
lifestyle. But the fact that none of our subjects' sleep 
time dropped below 4V4 hours suggests there is a limit 
beyond which sleep cannot be reduced. The limit for 
fragmentation of sleep is still unknown. 

Samuel Johnson, notes Webb (6), likened sleep to a 
gentle tyrant. To live on the best terms with a "gentle 
tyrant" one must learn the rules by which he governs. 
Being gentle, he permits us certain freedoms to mani- 
fest our individual variations and differences; being a 
tyrant, he will not permit us to live in total freedom, and 
abuses carry their ultimate consequences. 

We hope our studies will shed some light on the rules 
acceptable to this "gentle tyrant." 


1 . Aserinsky E, Kleitman N: Regularly occurring periods of eye 
motility and concomitant phenomena during sleep. Science 118:273- 
274, 1953. 

2. Dement W, Kleitman N: Cyclic variations in EEG during sleep 
and their relation to eye movements, body motility, and dreaming. 

Electroencephalogs Clin Neurophysiol 9:673-690, 1957. 

3. Johnson LC: Are stages of sleep related to waking behavior? 
Am Sci 61:326-338, 1973. 

4. Lubin A, Moses JM, Johnson LC, Naitoh P: The recuperative 
effects of REM sleep and stage 4 sleep on human performance after 
complete sleep loss: Experiment 1. Psychophysiology 11:133-146 

5. Johnson LC, Naitoh P, Moses JM, Lubin A: Interaction of 
REM deprivation and stage 4 deprivation with total sleep loss: Exper- 
iment 2. Psychophysiology 11:147-159, 1974. 

6. Webb WB: Sleep. The Gentle Tyrant. Englewood Cliffs, NJ: 
Prentice- Hall International Inc, 1975. 

7. Brictson CA, McHugh W, Naitoh P: Prediction of pilot per- 
formance: Biochemical and sleep-mood correlates under high work- 
load conditions. Paper presented at AGARD (Advisory Group for 
Aerospace Research and Development) Aerospace Medical Panel 
Specialist Meeting, Oslo, Norway, 29 April-3 May 1974. 

8. Williams HL: Sleep starvation and you. Army Information 
Digest 19(6): 10-18, June 1964. 

9. Marshall SLA: Night Drops: The American Airborne Invasion 
of Normandy. Boston: Little Brown &. Co, 1962. 

10. Johnson LC, Naitoh P: The Operational Consequences of Sleep 
Deprivation and Sleep Deficit. NATO AGARDograph 193, London, 

11. Woodward DP, Nelson PD: A user oriented review of the liter- 
ature on the effects of sleep loss, work-rest schedules, and recovery 
on performance. Office of Naval Research Report ACR-206, 1974. 

12. Gulevich G, Dement W, Johnson L: Psychiatric and EEG 
observations on a case of prolonged (264 hours) wakefulness. Arch 
Gen Psychiatry 15:29-35, 1966. 


Preventive Medicine in Vietnamese 
Refugee Camps on Guam 

In each experience such as the 
1975 evacuation of Vietnamese ref- 
ugees to Guam, we relearn the 
same lesson: relief operations fol- 
lowing civil or political disasters 
primarily involve providing for hu- 
man life support needs. Those 
needs include clean food and water, 
shelter, and sanitary waste dis- 

From April to October 1975, more 
than 120,000 Vietnamese refugees 
were sheltered in camps on Guam, 
presenting a major preventive med- 
icine challenge to military medical 
teams. In Military Medicine [142(1): 
19-28, Jan 1977], LCDR Robert 
Shaw, Jr. fMC), a member of the 
team sent from Environmental and 
Preventive Medicine Unit No. 6, de- 
scribes techniques used to prevent 
and control disease in the camps. 

Preventive medicine problems 
included locating a supply of pota- 
ble water, disposing of waste, and 

keeping food safe to eat. Eliminat- 
ing insects and rodents and con- 
trolling communicable diseases 
were other serious medical con- 
cerns. Lack of rapid communica- 
tions and cultural differences be- 
tween Vietnamese and Americans 
were practical problems. 

Common complaints among refu- 
gees included upper respiratory in- 
fections, conjunctivitis, skin rashes, 
and gastroenteritis. Many refugees 
complained of mild fevers, head- 
aches, sunburn, and ear infections, 
as well as minor injuries and fa- 
tigue. Malaria, an illness common 
in Vietnam, was diagnosed in about 
70 refugees, but was ultimately con- 
firmed in fewer than 5% of these 70 
patients; vector control measures 
prevented transmission of malaria 
in the camps. Six patients had 
dengue fever; ten refugees suffered 
from typhoid, and two from diph- 
theria. About 20 patients with active 

tuberculosis were discovered. 

Preventive medicine teams con- 
trolled the spread of vector-borne 
diseases by spraying garbage cans 
and other potential insect breeding 
sites with pesticides. Drainage pits 
filled with crushed rock and coral 
were effective in eliminating stand- 
ing water around field kitchens, 
showers, and washing areas. 

Medical personnel conducted 
mass immunizations against diph- 
theria, pertussis, measles, German 
measles and polio. A network of 
Army field dispensaries scattered 
through the camps, and several tent 
dispensaries manned by Vietnam- 
ese medical and paramedical per- 
sonnel, helped Navy medical teams 
provide efficient service. 

Dr. Shaw suggests that in plan- 
ning for future emergency evacua- 
tions of civilians, military medical 
personnel should consider commu- 
nications, transportation, identifica- 
tion of all available medical person- 
nel, cultural differences, and recre- 
ation for evacuees. Military medical 
teams used in civilian emergencies 
should include pediatricians and 
public health nurses, he adds. 

Volume 68, June 1977 



Managing Emergencies in the Dental Office 

CAPT Edward L. Mosby, DC, USN 

Although most dental emergencies can be pre- 
vented by conscientious management of patients, 
there are times when emergencies arise even after 
great pains have been taken to avoid them. Because 
of these rare instances, the dentist and his staff 
must know how to treat, and be equipped and ready 
to treat, acute conditions. A well-prepared dental 
team can manage most emergencies competently 
and safely without the aid of a physician. 

The best way to handle any dental emergency is to 
prevent it. Among the methods employed to antici- 
pate, intercept or prevent dental office emergencies 

• taking a thorough social and medical history of the 

• establishing good rapport with the patient. 

• positioning the patient correctly in the dental 

• monitoring vital signs. 

• giving the patient preoperative medication. 

• keeping emergency equipment and drugs nearby. 
Patient history. A minimal patient history should 

include answers to these questions: 

1. Are you presently under the care of a physi- 


If so, what are you being treated for? 
Do you have any allergies or sensitivities? 
Have you been ill recently? 
Have you ever had side effects from injections 
of Xylocaine or Novocain? 

6. Has a dentist ever had trouble extracting one 
of your teeth? 

7. Have you ever had prolonged bleeding from 
cuts, surgery or a tooth extraction? 

8. Do you, or does anyone in your family, have 

CAPT Mosby, an oral surgeon, is a staff member at Naval Re- 
gional Dental Center, San Diego, Calif. 92136. After 15 July 1977, 
he will be on the staff of Naval Regional Medical Center Great 
Lakes, HI. 60088. 


9. Have you ever suffered from any of the follow- 
ing conditions: 

kidney or urinary problems? 
liver trouble, hepatitis or jaundice? 
growth or tumor? 
high blood pressure? 
sinus trouble? 

heart disease, heart murmur, or rheumatic 
convulsions or dizzy spells? 

10. Have you recently lost or gained a lot of 

11. Are you now receiving any medication? 

12. Are you receiving radiation therapy? 

13. What problem led you to seek dental treat- 

This history should be signed and dated by the pa- 
tient and dentist. It should be a permanent part of 
the patient's record, and updated at least every six 

Good rapport. Every member of the dental treat- 
ment team should establish good rapport with the 
patient. The patient should be made to feel that he or 
she is the single most important patient in the den- 
tist's practice. Office surroundings contribute to this 
goal when they are kept simple and pleasant. 

Proper position. Some dentists still work with the 
patient in a sitting position. I recommend that all 
procedures, including oral surgery, be done with the 
patient in a reclining position, which prevents 
vasodepressor syncope (fainting) by increasing cere- 
bral blood flow (1). The dentist and assistant should 
be seated to avoid fatigue and stress. 

Vital signs. A recently published article [American 
Dental Association News, 31 May 1976, p 4) 
emphasized that "anyone who takes up a Novocain 
syringe has an obligation to take blood pressure." 
Recording each patient's blood pressure requires 
only a few moments of a trained assistant's time, and 
has many potential advantages (1,2): 

U.S. Navy Medicine 

• dental workers may discover unknown cardiovas- 
cular disease in the patient. 

• blood pressure readings may be needed as pre- 
operative data if an emergency occurs. 

• blood pressure readings can help the dentist 
decide whether an emergency is serious enough to 
require a physician's advice, 

• office personnel can stay familiar with the 
procedure and will not panic when they must take 
blood pressure in an emergency. 

Recording temperature before a dental surgical 
procedure may also be beneficial. Some oral sur- 
geons believe that patients with elevated tempera- 
tures tend to have more postoperative complications. 
Obviously the more sophisticated or complicated 
anesthetic procedures (sedation or general anesthe- 
sia) require monitoring additional vital signs such as 
pulse and respirations, and may warrant an ECG. 

Sedation. Sedating the patient may prevent some 
emergencies during dental treatment. Also many 
patients can benefit from preoperative sedation; 
such patients include those with anxiety, hyperten- 
sion, or a coronary disease such as angina or coro- 
nary occlusion, as well as patients who will undergo 
a lengthy dental procedure (3,4). Preoperative seda- 
tion can be given effectively as oral medication. 

Drugs and equipment. There are several require- 
ments for equipping an emergency set-up: keep it 
simple, keep it accessible, keep it mobile, and make 
sure you always remember the contents. 

An emergency drug cart should be only large 
enough to store equipment and supplies necessary to 
manage emergency situations. It should be mobile 
and complete— that is, contain its own source of 
suction and supply of oxygen. The style can range 
from a cart designed specifically for emergency use 
to a practical alternative, such as a mobile, three- 
drawer tool chest. Only a few drugs should be 
stored, and these should be readily available and 
organized so that office personnel will not be con- 
fused about where to find them in an emergency, 


For each emergency situation, common signs and 
symptoms should be listed on one side of a 3" x 5" 
card; on the other side are the plan of treatment and 
a list of drugs to be used in an emergency. If possi- 
ble, the card and drugs for each emergency should 
be placed in a labeled, zip-lock bag and stored in a 
drawer of the emergency drug cart. The drawer 
should be labeled to indicate which emergency bag it 

Here are examples of card descriptions for several 
emergency conditions; signs, symptoms and treat- 
ments are summarized from McCarthy \1). An aster- 
isk (*) indicates that the treatment may be beyond 
the dentist's ability and should be performed by a 
person qualified to continue treatment from that 


Signs and Symptoms (Side 1) 

1 . Frightened patient 

2. Cool, moist, clammy skin 

3. Pale appearance 

NOTE: Convulsions may occur. 

Treatment (Side 2) 

1. Place patient with head down 

2. Make certain patient has patent airway 

3. Administer aromatic spirits of ammonia 

4. Apply cold towel to forehead 

5. Give oxygen 


Signs and Symptoms (Side 1) 

(Seizure is a sign or symptom of a disease, not a disease in itself) 

1. Involuntary or bizarre movements 

2. Tongue biting 

3. Mental confusion 

4. Loss of consciousness 

NOTE: Tetanus, complete or incomplete, may be present (un- 
common) . 

Treatment (Side 2) 

1 . Insert oropharyngeal airway and give oxygen 

2. Place patient in semi-prone position 

3. Aspirate secretions as necessary 

4. Protect patient from injury: 

Cushion head 

Place gauze-wrapped tongue depressor in mouth 

5. Establish I.V. route (5% dextrose in water, normal saline, 
other solutions as necessary) 

6. Give Valium 5-10 mg I.M. or I.V. over 3 minutes* 


Signs and Symptoms (Side 1) 

1. Rapid short breaths (causing decrease of C02> 

2. Unconsciousness 

Treatment (Side 2) 

1. Reassure patient 

2. Place patient in comfortable position 

3. Have patient inhale and exhale through mouth while 
holding paper bag over mouth 

4. Give Valium 5-10 mg I.M. or I.V. over 3 minutes* 

Circulatory Depression 

Signs and Symptoms (Side 1) 

1. Palor 

2. Rapid, weak pulse 

3. Low blood pressure 

Treatment (Side 2) 

1. Place patient in supine position 

Volume 68, June 1977 


2. Make certain airway is open 

3. Administer oxygen 

4. Establish I.V. route (5% dextrose in water, normal saline, 
other solutions as necessary) 

5. Support circulation 

Hypotension -Ephedrine 12.5 mg I.V.* or Wyamine 15-30 

mg I.V.* 
Bradycardia— atropine 0.4-0.6 mg I.V.* 

Angina and Myocardial Infarction 

Signs and Symptoms {Side 1) 
1. Chest pain— may be radiating 

Treatment (Side 2) 

1. Place patient in supine position 

2. Assure patent airway 

3. Nitroglycerine 0.3 mg sublingual 

4. Amyl Nitrite aspirols under nose (for severe pain) 

5. Give oxygen 

6. If no relief, consider myocardial infarction and administer 
Demerol 25-75 mg I.M. or I.V.* 

Cardiac Arrest 

Signs and Symptoms (Side 1) 

1. Cessation of effective cardiac output: 

No pulse 

No blood pressure 



Treatment (Side 2) 

1. Provide basic cardiopulmonary resuscitation 

Ventilation— 12 per minute 

Cardiac compressions — 60-80 per minute 

2. Advanced cardiopulmonary resuscitation* 


Institute adequate I.V. (5% dextrose in water, normal saline, 
other solutions as necessary): 

1. Sodium bicarbonate {NaHCO)— one ampule (44.6 mEq) 
immediately and one ampule every 5 minutes of arrest 

2. Calcium chloride— One gm (1000 mg) in 10 cc 

3. Lidocaine HC1-100 mg I.V. 

3. Do not interrupt basic cardiopulmonary resuscitation for more 
than 5 seconds, for any reason 


Signs and Symptoms (Side 1) 

1. Wheezing- type dyspnea 

2. Effortless inspiration, prolonged expiration 

3. Distended chest 

4. Severe cyanosis 

Treatment (Side 2) 

1. Place patient in sitting position 

2. Assure patent airway 

3. Administer oxygen 

4. Two inhalations of isoproterenol HC1 

5. Epinephrine (1:1000) 0.3-0.5 ml subcutaneously (for severe 

6. Hydration (oral or I.V.) 


Signs and Symptoms (Side 1) 
1. Excessive thirst 

2. Frequent urination 

3. Acetone breath odor 

4. Nausea 

5. Collapse or coma 

Treatment (Side 2) 

1. Give sugar (candy, fruit juice, or sugar cube) 

2. If sugar fails, consider ketoacidosis and prepare to transport 
patient to medical facility 

3. Support cardiopulmonary system 

Central Nervous System Stimulation 

Signs and Symptoms (Side 1) 
1. Excitement and tremors 

Treatment (Side 2) 

1 . Place patient in supine position 

2. Assure patent airway 

3. Give oxygen 

4. Reassure patient 

5. If convulsions begin, give Valium 5-10 mg I.M. or I.V. over 3 

Allergic Reaction 

(for sample emergency kit, see Figure 1) 

Signs and Symptoms (Side 1) 

1. MUd: 

Urticaria, pruritus, skin eruptions, mild angioneurotic 

2. Severe: 

Involvement of bronchial tree (congestion) 

Respiratory depression 


Treatment (Side 2) 

1. Place patient in supine position 

2. Assure adequate airway 

3. Give oxygen 

4. Support respiration and circulation 

5. For mild reaction— 50 mg diphenhydramine HC1 (Benadryl) 

6. For severe reaction— obtain an I.V. route— 50 mg diphenhy- 
dramine HC1 (Benadryl) I.V.* 

FIGURE 1. Emergency kit for treating allergic reactions in- 
cludes (clockwise from top left) diphenhydramine HCI tablets, 
diphenhydramine HCI in liquid form for an injection, two dif- 
ferent size needles, and syringe. 


U.S. Navy Medicine 

Anaphylactic Shock 

Signs and Symptoms (Side 1) 

1. Shock, or varying degrees of hypotension 

2. Pulmonary edema, cardiac arrest, or both 

3. Laryngeal obstruction, bronchospasm, or both 

4. Angioedema, urticaria, and generalized pruritus 

5. Urgency or incontinence of urine or feces 

6. Nausea, vomiting, diarrhea, gastrointestinal hemorrhage, 

NOTE: Convulsions may occur. 

Treatment (Side 2) 

1 . Place patient supine on hard surface 

2. Cardiopulmonary resuscitation 

3. Start I.V. (5% dextrose in water, normal saline, other solu- 
tions as needed) 

4. Epinephrine 1:1000* 

Subcutaneous— 0.3-0.5 ml in 10 cc over 5 minutes* 

5. Treat hypotension and shock 

6. Treat bronchospasm* 

Aminophylline— 250 mg I.V. (slowly)* 
Hydrocortisone — 100 mg I.V. (slowly)* 


Certain steps are essential in treating a dental 
emergency: assure a patent airway, support respira- 
tion, support circulation, aspirate secretions as 
needed— and call for help from a nearby physician or 
rescue squad, whose phone numbers should be 
posted at every office telephone. 

While the treatments listed above that are marked 
with an asterisk may or may not be rendered by the 
dentist, the drugs used in these procedures should 
be available in the dental office. Items not listed that 
may be included on an emergency drug cart include 
assorted sizes of oxygen masks, a means of deliver- 
ing positive pressure oxygen, and equipment for 
endotracheal intubation. Narcotics should not be 
kept in the cart because they are often stolen. 

I also suggest that all dentists become certified in- 
structors in cardiopulmonary resuscitation so they 
can teach their office personnel the basic techniques , 

Successful management of an emergency depends 
on having adequate equipment and supplies, and 
knowing how to use them rapidly and logically. 
(Along the same lines, dentists must also know the 
components, safe dosages and capabilities of drugs 
they administer routinely, such as Xylocaine.) Every 
dental office should conduct emergency drills at least 
once a month to ensure that emergency equipment 
and supplies are accessible and work properly. At 
this time, inventory can be taken and outdated sup- 
plies replenished. 

Dentists can protect themselves from lawsuits by 
preparing well for emergencies. According to 
McCarthy (I), dentists can be legally liable for 

damages if they make a wrong diagnosis of an emer- 
gency condition "caused" by dental care or treat- 
ment. Furthermore, dentists who do not have ade- 
quate training and equipment to give definitive 
treatment for emergencies can be liable for the con- 

Dentists who administer local anesthetics or other 
potentially anaphylactic agents may soon be required 
by law to know how to establish a clear airway, 
deliver oxygen (artificial ventilation), administer 
fluids and medications by parenteral and intravenous 
routes, and perform cardiopulmonary resuscitation. 
If such laws are passed, the dentist who learns these 
techniques to prepare for emergencies will be one 
step ahead. 


1. McCarthy FM: Emergencies in Dental Practice. Philadel- 
phia: W.B. Saunders Co, 1972, p 260. 

2. Luechauer H: Blood pressure: your easiest and most im- 
portant tool. General Dentistry 24(4):46-47, 1976. 

3. Clark HB Jr.: Practical Oral Surgery. Philadelphia: Lea & 
Febiger, 1965, pp 50-85. 

4. Reynolds DC: Pain control in the dental office. Dent Clin 
North Am 15(2):319-325, 1971. 


Simple Technique 

for Collecting Live Ticks 

Navy entomologists have successfully tested a 
simple, rapid technique for collecting large samples of 
live ticks. 

Using a method first proposed in 1965, LCDR R.H. 
Grothaus (MSC), J.R. Haskins, and J.T. Reed placed a 
block of dry ice in an aluminum pie pan and centered 
the pan on a nylon panel on the ground. The melting ice 
gave off carbon dioxide, which attracted ticks, while the 
pan prevented the ticks from coming into direct contact 
with the ice. After an hour, any ticks that had moved 
onto the nylon were counted, and shaken or brushed 
from the nylon into another pan. This procedure made 
it possible to collect large numbers of undamaged ticks 
rapidly, with minimal handling. The researchers were 
able to establish 80 sample sites in about 5 hours, 
including recovery and storage or release of the ticks. 

"A Simplified Carbon Dioxide Collection Technique 
for the Recovery of Live Ticks (Acarina)" was published 
in the Journal of Medical Entomology [12(6):702, 1976]. 
Copies are available from the Office of Technical Infor- 
mation and Professional Publications, Bureau of Medi- 
cine and Surgery (Code 0010), Navy Department, 
Washington, D.C. 20372. 

Volume 68, June 1977 


Missed Fracture Dislocation of the 
Elbow with Translocation of the Radius 

CDR Alvin H. Crawford, MC, USNR 
CDR Earl F. Evans, MC, USN 

In a review of 183 reports of dislocation of the 
elbow in the orthopedic literature, we failed to find a 
description of an irreducible fracture dislocation of 
the elbow with translocation of the radius. After such 
a dislocation, the radius articulates with the trochlea 
and the ulna with the capitellum. This report is a 
description of such an injury. 


M.W. is a 12-year-old female who came to the 
Orthopedic Service of Naval Regional Medical Cen- 
ter San Diego, Calif., on 9 Sept 1971, She had been 
seen several hours before at an outlying facility. A 
review of her history revealed that earlier that day 
she had fallen on her left arm while trying to leapfrog 
over a tractor tire. The patient was unable to recall 
the exact mechanism of her injury. Roentgenograms 
accompanying the patient were interpreted as show- 
ing a posterior dislocation of the elbow (Figures 1 
and 2). A closed reduction and splinting were per- 
formed. Post-reduction roentgenograms (Figures 3 
and 4) were believed to show adequate reduction and 
the patient was allowed to return home, with 
instructions to use ice packs and elevate the injury. 

The following morning, on her return for a cast 
check, the patient complained of marked pain about 
the elbow. She felt pain when she extended her 
fingers passively, and also when she flexed them 
actively. Her distal capillary filling, sensation, and 
motor function were judged normal. The immobiliz- 
ing splint was changed to relieve pressure and the 
patient was admitted to the hospital for two days for 
observation, elevation, and ice pack treatments. 

Dr. Crawford is a pediatric orthopedic surgeon on the staff of 
Henry F ° r d Hospital, 2799 West Grand Blvd., Detroit, Mich. 
48202. CDR Evans is an orthopedist on the staff of Naval Region- 
al Medical Center Oakland, Calif. 94627. 

FIGURE 1. Original lateral view of posterior dislocation of 
the left elbow. 

During that period she regained painless active and 
passive motion of her fingers. She was discharged to 
outpatient care, and her arm was immobilized for 
two weeks in a posterior splint. After two weeks she 
started to perform range-of-motion exercises for her 
elbow and forearm. 

In the following six weeks she made very slow 
progress, gaining only 35 degrees of motion (60 to 95 
degrees in flexion, 50 degrees in supination, and 
degrees in pronation). In a second review of her 
roentgenograms, Dr. Crawford found that although 
on lateral roentgenograms the radial head pointed 
directly to the capitellum, anterior-posterior views of 
the injury showed the radius to be on the trochlear 
side of the humerus, and the ulnar coronoid process 
articulating on the capitellum. Further evaluation 
revealed that there was, in fact, a medial dislocation 
of the proximal radius, with a fracture fragment of 
the radial head remaining in the radial notch 
(compare Figures 5 and 6 with Figures 7 and 8). 

Open reduction was performed in November 1971. 
There was found to be a fibrous ankylosis of the 
radius, which was in a dislocated position on the 
medial side of the ulnar coronoid process. The frag- 
ment which had fractured off the radial head was 


U.S. Navy Medicine 

FIGURE 2. Original anterior-posterior 
view of posterior dislocation of the left 

FIGURE 3. Post-reduction roentgeno- 
gram shows dislocation of left elbow 
with posterior splint applied. Note that 
capitellum appears to articulate with 
radial head. 

FIGURE 4. Anterior-posterior view 
shows reduction of left elbow disloca- 
tion. Ulna appears to articulate with 
ulnar groove, but radius articulates with 

FIGURE 5. Lateral view of left elbow two 
months after reduction. Radial head appears 
to articulate with capitellum. 

FIGURE 6. Anterior-posterior view of 
left elbow two months after reduction. 
Radial head appears to articulate with 
trochlea and ulna appears to articulate 
with capitellum. 

FIGURE 7. Anterior-posterior 
view of normal right elbow, in 
which radial head articulates 
with capitellum. 

FIGURE 8. True lateral view of normal right elbow. Radial 
head articulates with capitellum, and there is no increase in 
joint space between humeral condyles and ulna. 

Volume 68, June 1977 


FIGURE 9. View of left elbow with arm ex- 
tended. Note loss of joint space. Extension is 
limited approximately 45 degrees. 

FIGURE 10 (left). Anterior-posterior and lateral views of left elbow five 
months after injury occurred. In both views, joint space is markedly 
diminished and radial head appears to articulate with capitellum. 
FIGURE 11 (above right). Anterior-posterior view of left elbow five months 
after injury occurred. Note that ulna articulates in trochlear groove, and 
part of radial head appears to be absent. There appears to be a synostosis 
of the proximal radius and ulna. 

* < < 

FIGURE 12. Clinical photograph of patient one year after in- FIGURE 13. Clinical photo of patient one year after injury, 
jury. Note full flexion of right elbow and 100-degree flexion of Note full extension of right elbow and 45-degree limitation of 
left elbow. left elbow extension. 


U.S. Navy Medicine 

found in the radial notch of the ulna, representing 
approximately 35% of the epiphysis of the radial 
head. There were no loose bodies in the elbow joint. 
Following blunt dissection along the proximal half of 
the radius, reduction was accomplished, but was 
very unstable due to loss of the posterior medial half 
of the radial head and its retaining ligaments. Pin 
fixation of the radius to the ulna, with the forearm in 
neutral rotation, was required to maintain the reduc- 
tion after removal of the radial head fragment. 

Following reduction, range of motion was from 175 
degrees of extension to 35 degrees of flexion. After 
an uncomplicated postoperative course, active range 
of motion with protective splinting was started on the 
12th postoperative day. The pin was removed in the 
fifth postoperative week, followed by successive 
casting to regain extension. Progressive bony synos- 
tosis occurred between the proximal ends of the 
radius and ulna. 

On reevaluation 18 months after the injury and 
16 '/2 months after open reduction, the patient had no 
pain in her elbow and had few complaints about her 
loss of motion. On examination we found a 30-degree 
flexion contracture with further flexion to 80 
degrees. There was complete synostosis with the 
forearm in neutral position, but she had only partial 
(15 to 20 degrees) pronation and supination at the 
wrist. There was no varus or valgus deformity at the 
elbow (Figures 9, 10, and 11). Clinical photographs 
showed a range of motion similar to that of her 
normal right arm (Figures 12 and 13). 


Although we found it difficult to reconstruct this 
injury because the patient could not recall exactly 
how she had fallen, we believe that her elbow under- 
went stresses which usually would have caused a 
posterolateral dislocation of the elbow. Because her 
distal limb was pinned down, the ulna shifted to a 
posterolateral position, as is common, but the radial 
head fractured at its posterior medial aspect and 
dislocated across the coronoid process to the ulnar 

Some basic procedures in managing fracture dis- 
locations could have been of tremendous benefit to 
this patient. For example, following reduction, the 
joint could have been placed through its full range of 
motion, which at the elbow includes pronation and 
supination as well as flexion and extension. Then the 
injury might have been recognized earlier, although 
flexion, extension, pronation and supination were 
50% of normal capability. Of course, comparison 

views of the opposite elbow would have been invalu- 
able; however, comparison views are not always 
ordered for patients as old as this girl. 

One rule that is usually considered important was 
not completely reliable in this instance. That rule is: 
following reduction of an elbow dislocation the radial 
head should always point directly to the capitellum in 
all views. But in this patient, the radial head pointed 
to the capitellum on the lateral view only (Figures 3 
and 5), 

At the time of surgery, transfixation with pins was 
necessary to maintain the radius in its reduced posi- 
tion after the proximal fragment that had been 
embedded in the radial notch was excised. There 
was no trace of the orbicular ligament. Excision of 
the radial head might have given her better flexion 
and extension, but probably would not have im- 
proved pronation or supination due to the amount of 
soft tissue stripping required to gain reduction. 

The patient is now clinically well and has no desire 
to undergo further surgery. We believe her experi- 
ence is unusual and instructive. 


Nongonococcal Urethritis: 

A Growing Problem in the Navy 

Nongonococcal urethritis is a much greater problem, 
and is more closely associated with gonorrhea, than has 
generally been recognized, says a Navy epidemiologist. 

Writing in the American Journal of Epidemiology 
[104(5):535-542, 1976], CDR Lee J. Melton III (MC) 
describes his study of the relative frequency of gonor- 
rhea and nongonococcal urethritis among all active- 
duty Navy and Marine Corps personnel between 1966 
and 1974. Results showed that the annual incidence of 
nongonococcal urethritis in the Navy is substantial, 
equaling or exceeding the incidence of gonorrhea in 
most areas studied. Also, the incidence of nongonococ- 
cal urethritis and the incidence of gonorrhea are rising 
at the same rate. 

If civilian data confirm the close relationship between 
nongonococcal urethritis and gonorrhea, clinicians will 
not be able to assume that all urethritis is caused by 
Neisseria gonorrhoeae and that penicillin is the treat- 
ment of choice. They will have to give more thought to 
the source and spread of the patient's infection, says 
the author. 

"Comparative Incidence of Gonorrhea and Non- 
gonococcal Urethritis in the United States Navy" is 
available from CDR Melton at the Bureau of Medicine 
and Surgery (Code 5511), Navy Department, Washing- 
ton, D.C. 20372. 

Volume 68, June 1977 



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